Provider Demographics
NPI:1104370063
Name:NEROSA, RAISA ANGELICA
Entity Type:Individual
Prefix:
First Name:RAISA ANGELICA
Middle Name:
Last Name:NEROSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13921 KORNBLUM AVE UNIT 18
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-8179
Mailing Address - Country:US
Mailing Address - Phone:310-951-7059
Mailing Address - Fax:
Practice Address - Street 1:13921 KORNBLUM AVE UNIT 18
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-8179
Practice Address - Country:US
Practice Address - Phone:310-951-7059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74726183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist